Provider Demographics
NPI:1376668624
Name:BENNETT, ERIC KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:KENNETH
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3139
Mailing Address - Country:US
Mailing Address - Phone:541-451-5577
Mailing Address - Fax:541-451-5538
Practice Address - Street 1:1786 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3139
Practice Address - Country:US
Practice Address - Phone:541-451-5577
Practice Address - Fax:541-451-5538
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGHFDMedicare UPIN